Form Ri 25-49 - Verification Form - Full-Time School Attendance printable pdf download

Form Approved

Verification of Full-Time

OMB No. 3206-0215

School Attendance

United States Office of Personnel Management

Retirement Surveys and Students Branch

1900 E St., NW

Washington DC 20415-3563

Claim Number

For Agency Use Only

III

Social Security Number

Certification Period

Date

Student's Name

Please return the completed form to us within 30 days to avoid interruption of

payments for the student.

The Office of Personnel Management is verifying the information you previously provided regarding the full-time

attendance of the student named above. We must be sure that benefits are properly paid and continued eligibility

requirements are met. Please have the verification form on the other side completed and signed by an official of the

educational institution the student attended during the certification period shown above. We request that the student

complete Part A and sign the release of information statement below. This will allow us to obtain any information we

need from the school. Please return the completed form in the envelope provided to: Office of Personnel

Management, Retirement Surveys and Students Branch, 1900 E St., NW, Washington DC 20415-3563 or fax the form

to (202) 606-0022. If the student named above has attended more than one school during the requested certification

period, you may duplicate the verification form for each school as necessary. Please call us at 1-888-767-6738 or

(202) 606-0249 if you have any questions.

PART A (To be completed by the student)

1. Did you attend more than one school during the certification period shown above?

If yes, you must provide verificaton from each school.

Yes

You may photocopy this form as needed.

2. Do you intend to return to school for the next school year?

Yes

3. Estimated date of return if answered yes to question 2.

4. Student's Phone Number

(

)

m m

5. I authorize the release of information about school attendance to OPM.

7. Date

6. Student's Signature:

________________________________________

m m

Public Burden Statement: We think this form takes an average of 1 hour per response to complete, including the time for reviewing instructions,

getting the needed data, and reviewing the completed form. Send comments regarding our estimate or any other aspect of this form, including

suggestions for reducing completion time, to the Office of Personnel Management, OPM Forms Officer (3206-0215), Washington, DC

20415-7900. The OMB Number 3206-0215 is currently valid. OPM may not collect this information and you are not required to respond unless

this number is displayed.

19922

RI 25-49

Revised October 2002

Form Ri 25-49 - Verification Form - Full-Time School Attendance

Related Articles

Related forms

Related Categories